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“But I’ve also tried”

Predominance of the medical and parental discourses in dietetic consultations with an obese Danish child.
“Mais j’ai fait ce que j’ai pu!” - Prédominance des discours médicaux et parentaux dans les consultations diététiques avec une jeune obèse danoise.
Lisa Koustrup, Inge Wittrup, Morten Deleuran Terkildsen and Claus Vinther Nielsen

Abstracts

This paper departs in the problem of rising obesity amongst Danish children. The aim is to show how meanings about childhood obesity are constructed in the meeting between the dietician, the obese youngster and parent. The empirical data is based on observations of meetings with the dietician, a youngster named Anna, and Anna’s mother. The study draws on various multi-disciplinary research concerning children and their food worlds in order to broaden the perspective. In particular, the analysis has been inspired by the concept of a joint discourse of ‘being and becoming’, and the idea that children’s lives are structured through a ‘generational order’. The meeting observations reveal that whilst biomedical and parental discourses of obesity are prevalent, a child’s discourse is lacking. This paper suggests that the key issue at stake is an improvement in the knowledge of obese children’s food worlds, which might lead to an enhanced dietetic approach.

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Framing the problem of childhood obesity

Anna’s mother: “I try to tell her so many times...but she loves food so much – I have tried everything”

Anna: “But I’ve also tried”

Mother: “The health visitor told us she needs to lose weight. I got a letter and answered immediately – I’m so pleased. She really wants to lose weight”

Dietician (to Anna): “It’s important that you want to lose, not just your mum, the doctor and others”

Mother: “She doesn’t like salad”

Anna: “I do! But sometimes it’s too much”

Dietician: “How is your daily life with food? If you tell me, I can see what you eat and how we can find a food system which suits you individually.”

  • 1 Danish Ministry of Health www.sst.dk consulted 1.10.2011
  • 2 Region Midtjylland data 2008,2009,2010
  • 3 Interviews with dieticians in 2010
  • 4 http://www.regionh.dk/topmenu/Nyt_Presse/Nyheder/2008+arkiv/Arkiv/Etniske+minoriteter+har+massive+s (...)
  • 5 http://www.cfk.rm.dk/projekter/sundhedsfremme+og+forebyggelse/afsluttede+projekter/v%C3%A6gtstop+fo (...)

1This section of dialogue is from Anna’s first meeting with the dietician and her mother. Whilst the dietician tried to forge contact with Anna, her mother intervened, and Anna’s response: “But I’ve also tried” evokes a cry for help. This early exchange in the meeting prompted speculation about Anna’s position, and whether she was being heard amongst the discourses occurring around her. Anna represents a growing number of obese children in Denmark1, and this paper departs in the specific problem of poor results amongst youngsters receiving dietetic guidance in Eastern Jutland – a region in Denmark-. Since 2006, Region Midtjylland’s Centre for Public Health has offered dietetic interventions to 85 obese youngsters aged 13-16 years2. There is no data which shows the long-term effect of the interventions, but the number of teenagers losing weight is too low, and the drop-out rate is too high. Dieticians suggest various reasons for this, such as parents abandoning control of children’s diets and increased peer influence3. Various studies support this: for example, ‘fast food’ is normalised amongst youngsters (Groth et al., 2009), and peers influence food choices (James, 2009). These factors affecting children’s dietetic behaviour can be seen as an outer layer, but by unpeeling a deeper layer concerning children’s private food worlds, new perspectives on childhood obesity can be revealed. Another element to consider in relation to my study is that obesity amongst ethnic minorities in Denmark is an established problem, and the Danish government is aware of this.4 Region Midtjylland is one example of a health authority which has focused on weight-loss initiatives amongst migrants for several years, as the incidence of obesity, diabetes and other lifestyle diseases is high within this group.5 The aim of this paper is to show how meanings about obesity are constructed in the meeting between the dietician, the youngster and parent through discourses. By drawing on multi-disciplinary research into childhood and children’s private food worlds, perspectives on childhood obesity will be broadened. This new knowledge may ultimately lead to an enhanced dietetic approach.

Perspectives on children

2This paper is about children and their private food worlds. Childhood research today sees the ‘being’ child as an active agent in shaping their social worlds (Corsaro, 1997), whilst the ‘becoming’ child is viewed as lacking competences for their future adulthood (James et al., 2004). Yet, instead of seeing children’s lives as separate temporalities of present and future, Uprichard (2008) suggests that a new joint discourse of ‘being and becoming’ can help us to understand the process of children’s development. Uprichard says: “Looking forward’ to what a child ‘becomes’ is arguably an important part of ‘being’ a child. By ignoring the future, we are prevented from exploring the ways in which this may itself shape experiences of being children” (Uprichard, 2008: 306). Indeed, the meeting youngsters have with the dietician concerns both their present and future lives, thus concepts of ‘being and becoming’ underlie practice. Uprichard argues for a greater frequency of the use of ‘being and becoming’ in research with children, because in their accounts, children actively look ahead to the future from their present life perspectives (ibid: 306). This concept provides a link throughout the paper because it emphasises the need to illuminate obesity from the child’s perspective, by focusing on how youngsters see themselves both now and in the future, against the idea that they actively shape their lives through their agency.

3Another supporting concept concerns the ‘generational order’, which socially categorises children in relation to adults (Alanen in Qvortrup et al., 2009). Alanen suggests that children are positioned within an asymmetrical system of relations, without necessarily having equal participation opportunities. Alanen describes a generational order as a structured network of relations between generational categories that are positioned and act within necessary interrelations with each other” (ibid: 162). This is closely linked to children’s agency, because the social order of generational relations affects the extent of children’s agency and ‘power’ (ibid: 170). This idea supports the analysis by underlining how a ‘hierarchical’ generational order influences youngsters’ social position, and thus their participation in the dietetic meeting.

Food as both a nutritional and a social concept

4This paper concerns food as both a nutritional and a social concept. Food provides the body with nutrients for ‘good health’, yet it is also a deeply social concept, not least of all regarding maternal care (Caplan, 1997). Fischler emphasises food’s heterogeneous character: on one hand, food provides nutrients for the body, and on the other, consuming certain foods differentiates one’s cultural identity, so food is also a cultural symbol (Fischler, 1988: 279-280). The structuralist anthropologist Levi Strauss analyses food in terms of binary oppositions, such as raw/cooked, where cooking raw food transforms it from ‘nature’ to ‘culture’ (Levi Strauss, (1997). The semiologist Barthes argues that the preparation, cooking and serving of different foods has the power to communicate situations, (Barthes, 1997), whilst Bourdieu suggests that people are pre-disposed to certain tastes based on their social class (Bourdieu, 1984). These examples underscore the idea that food is a social concept, yet at the same time, Lupton argues that many nutritionists see the social import of food as an impediment to people’s ability to eat a prescribed, ‘healthy’ diet (Lupton, 1996: 7).

Discourses about obesity

5In exploring how different discourses construct meanings about childhood obesity in the dietetic meeting, the focus is on a biomedical, a parental and a child’s discourse. Following Foucault’s notion of discourse, discourses can be described as repetitive systems of language. Foucault argues that in certain cultures, over certain periods of time, dominant discourses ‘fix’ the norms of knowledge (Foucault, 1981). Changing beliefs in medical science over the centuries are an example of how prevalent beliefs become universal ‘truths’ in different epochs, such as ideas about ‘health’. At the same time, Fairclough argues that it is important to consider discourse in the social context as both shaping and being shaped by language: “Viewing language use as social practice implies that it is [...] always a socially and historically situated mode of action, in a dialectical relationship with other facets of ‘the social’ (its ‘social context’) – it is socially shaped, but it is also socially shaping, or constitutive.” (Fairclough, 1995: 131, author’s italics). This concept affirms the need to examine the fluidity of constructions of meanings about childhood obesity, and how discourses do not stand alone, but in relation to other discourses.

6In this regard, I have found it useful to include reflections from Ørntoft and Madsens book “Overweight” (2005), as this text presents first-hand accounts (‘narratives’) of being an obese youngster in Denmark today, from experiences in school, with the dietician, and in society as a whole. These accounts not only provide references about life in Denmark for youngsters, but importantly suggest dominant current discourses about obesity and frame the social context for my study.

The methodological perspective

7This paper’s focus is on different discourses of obesity, and the data comes from observations of three 40 minute meetings involving the single case of 12 year old Anna, her mother, and the dietician, over three months between September and November 2011 in the dietician’s office. Whilst other observations of families attending the dietetic meetings had been undertaken, the observation of Anna was unique because she was one of only two ethnic minority respondents I observed, whom I managed to follow through each meeting. The other family group were immigrants from Iraq, where both parents attended, whilst Anna’s parents were of African origin. The dietician did not ask Anna’s mother about her origins, but her appearance suggested Central African ancestry. It should be noted that in some African cultures the corpulent body is held in esteem, but, once again, this was not an issue for discussion in the dietetic consultation.6 As a consequence of cancellations, it proved impossible to follow all the planned meetings with all the respondents, therefore I have chosen explicitly to concentrate on Anna. An ideal situation for me would have been to have observed perhaps 4 or 5 different families over the three months throughout, but it was not possible in practice to “drop in” and observe meetings as time slots had to be co-ordinated with the dietician, some overweight youngsters did not want to be observed, and others either cancelled or dropped out of the intervention. As a consequence, the only complete data I acquired was from Anna’s family, who attended all booked consultations with the dietician.

8It has been important in this study to gain insight into both how new families experience dietetic practice for the first time, and how dietetic practice experiences new families. From information given to me by dieticians, it is normal for children to be accompanied by a parent – especially a mother. Anna attended all the dietetic meetings with her mother, and on one occasion, her father and brother as well. This revealed entirely new dynamics in the interaction between Anna and the dietician, and will be explained later on in the paper.

9I observed the meetings from start to finish, and once they had ended, Anna and her mother always left the room, so no subsequent discussions between them were observed. I wanted to explore how Anna was able to articulate her perspectives to the dietician, yet the observations revealed that this was obstructed by the presence of family members.

10Although the data from a single-case study is highly limited, rich and useful data can still be collected, as Mattingly has demonstrated in various single studies such as observations of one patient with one doctor (Mattingly, 2008). There are, nonetheless, major disadvantages in single case studies. Single studies are not representative, nor can they be analysed comparatively to look for patterns and differences. I cannot use the data to conclude why the success rate for weight loss is poor in this area of Denmark, nor can I suggest what characterises meetings between dieticians and children. Moreover, I cannot generalise about obese children with immigrant backgrounds. What this study does allow me to do, however, is to enter a dietetic meeting involving an obese child with immigrant parents who is seen to be under pressure to succeed at losing weight not from the dietician, but the parents. The findings suggest the existence of certain complexities in the flow of information from the dietician to the child and vice versa, but these are not language difficulties, as Danish is Anna’s native language and her parents speak fluent Danish. Rather, they point to disturbances from the parent(s), leading me to anticipate that parental dominance in these meetings may occur in other meetings – not least of all regarding youngsters with immigrant backgrounds, and may lead to a lack of focus on the child’s private food world. Indeed, the findings imply that if children’s voices are being muted in these dietetic meetings, then the child’s discourse of “being and becoming” is being overlooked within both biomedical and parental (generational) discourses. This single study is a relevant case in itself, as it points to possible impediments to weight-loss success amongst some children receiving dietetic guidance, and possibly amongst some children with immigrant backgrounds.

11In this section, the problem of childhood obesity in Eastern Jutland has been outlined, and a theoretical framework concerning children, food and discourses has been presented. In the next section, we meet Anna in her first meeting, which reveals how Anna’s obesity is problematised by the dietician, the parent and Anna.

Introducing Anna

  • 7 Data from interviews with RM dieticians 2010
  • 8 Anna is 156cm. high and weighs 70 kg., with a child’s Body Mass Index (BMI) of almost 29, which is (...)

12Dietetic guidance is offered by Region Midtjylland over a year, and often over 4-6 months. The first meeting lasts an hour, and subsequent meetings last 30 minutes.7 The meetings are optional. Anna is 12 years old, and clinically obese.8 Anna represents a growing number of obese Danish youngsters with immigrant backgrounds who are referred to dietetic practice from their doctor. Anna is exceptional amongst the other obese youngsters I met because she attends a private school for both Danish and international children from kindergarten to 9th grade. This school will only enrol children who pass tests for scholastic ability. Therefore, not only is Anna a gifted pupil, her parents are intent on retaining her academic talent by paying for a renowned private school (where all teaching is undertaken in Danish), suggesting they are very focused on Anna’s success. Furthermore, Anna was encouraged to do several paid activities every week, such as dance and gymnastics. These aspects are important to note as they construct a picture of Anna and her parents implying that Anna is under some pressure to succeed in different areas of her life.

13For their first meeting, Anna and her mother arrived on time, and the dietician showed them into her office. Anna and her mother sat opposite the dietician at her desk, whilst Anna’s mother watched the dietician intently. The dietician began with informal chatter before explaining that Anna’s doctor had diagnosed her as being obese, and the dietician’s role was to help her to lose weight. The dietician asked Anna to list out what she ate on an average day, and Anna went through her diet, including her visits to the Junior Club at school 2-3 times a week, where she bought noodles, yoghurt or bread rolls. The dietician then asked what Anna ate after school:

Anna: “If I haven’t bought anything at the school club, I eat toast”

Mother: “I don’t like it – ham and cheese. She eats too many toasted sandwiches, puts four slices in the machine”

Anna: “But I don’t eat them all the time”

Dietician: “So what else do you like?

Anna: “Just bread... mainly brown toast, white rolls and of course rye bread”

14Anna’s mother’s comment seemed to momentarily interrupt the dialogue between Anna and the dietician, yet the dietician kept a visual focus on Anna, with a soft tone, suggesting she wanted to create a ‘bond’ with Anna. Studies reveal that bad experiences with health professionals can affect overweight youngsters’ motivation to lose weight. Ørntoft et al. present an account from one girl who told how the health visitor made her feel ‘abnormal’ because she was obese. Rather than feeling encouraged, she just wanted to eat a piece of cake after the meeting, because she was so upset (Ørntoft et al., 2005: 38). Anna’s dietician was quite the opposite: in the dialogue passage at the beginning of the paper, she told Anna that it was important that she wanted to lose weight for herself and not others, suggesting that she raised Anna to the level of autonomous agent in her life, in charge of her ‘becoming’, and not a passive recipient (Qvortrup, 2009). When Anna explained what she ate for dinner, her mother intervened by saying: “We change our food every day – they get potatoes, meatballs with mashed potatoes, sometimes rye bread, rice, sausages, pasta with minced beef, salad, baked chicken with bread flutes...” The dietician then asked Anna how much she ate, and after Anna explained, her mother said: “She easily takes two portions - I’ve been teaching her to take half portions.” I interpreted these comments from Anna’s mother in different ways: on one hand her mother seemed to want to convince the dietician that she was a good mother and provided a nutritional and delicious diet, whilst on the other hand she blamed Anna for eating too much of her food, therefore implying that it was not her fault that Anna was overweight, almost exonerating herself of any blame.

15The dietician explained that according to nutritional guidelines, Anna was eating too much. She showed Anna a diagram illustrating a plate divided into a ‘Y’ shape, where 1/5 of the plate should be protein, 2/5 carbohydrates, and 2/5 vegetables, and recommended that Anna try to separate her portions using a similar method. The dietician told Anna that they could discuss ways of reducing her food intake together, suggesting that Anna should be part of the process to find a weight loss strategy. Anna’s obesity appeared to be framed in a nutritional discourse: the dietician was piecing together a picture of Anna’s life with food in terms of what, when and how much she ate, yet without the social elements of Anna’s food world. By this stage, Anna’s perspectives were yet unheard.

Different perspectives on Anna’s food world

16Anna’s mother’s comments are remarkably illuminating in this first meeting, revealing her parental role in family food provision, her efforts to teach Anna to eat less, and her disapproval of Anna’s over-eating. Had Anna’s mother been less prominent in the dialogue, Anna might have had an opportunity to reveal aspects of her food world, such as why she liked eating four rounds of toast after school. The generational parent-child social order was implied, where Anna’s mother answered many of the dietician’s questions before Anna could, causing Anna to seem rather ‘invisible’. However, if children are really the experts in their own lives (Corsaro, 1997), then Anna held the key to knowledge about her private world, not her mother. It was therefore Anna’s own discourse that would unfold knowledge about her life with food.

17By the end of the first meeting, Anna’s food intake was clear, yet her private food world remained hazy. The dietician wanted to know what, when, how often and how much Anna ate, and meanings about her obesity were framed in either a biomedical discourse concerning food intake, or a parental discourse suggesting parental responsibility. The fact that Anna needs to lose weight emphasises her ‘being and becoming’, and the dietician is very much focused on a future trajectory. Yet as Uprichard notes, in order to understand children’s futures, we need to understand their present lives, because children’s narratives often anticipate their ‘becoming’ (Uprichard, 2008: 311). This suggests that Anna’s dialogues may indicate her future aspirations from her present perspective, and which would therefore impart knowledge to the dietician. In this section, Anna has been introduced, and an attempt has been made to illustrate the complexity of the different discourses about child obesity occurring in the dietetic meeting.

A biomedical discourse

18We will now turn to the concept of biomedical discourses, and examine how they frame the concept of childhood obesity. The dietician fulfils a professional role by following a biomedical model which focuses on food as nutrition. According to the Danish Union of Clinical Dieticians, dieticians are trained to understand the connection between nutrition, illness and health, which is why they focus on a nutritional biomedical perspective.9 Hahn et al. describe ‘biomedicine’ as “the predominant medical theory and practice of Euro-American societies” (Hahn et al., 1983: 305), and maintain that biomedicine’s central concern is not individuals, but “their bodies in disease” (ibid: 312). Hepworth argues that biomedical approaches to eating disorders have changed little over the last century, where the focus is still on weight monitoring, which fails to consider the social and cultural context behind eating disorders (Hepworth, 2007: 374). Lupton even suggests that health discourses have replaced religion as the central institution governing bodily conduct, contributing to the “moral regulation of society, focusing as they do upon ethical and moral practices of the self” (Lupton, 1995: 4).

19Three weeks later, Anna and her mother returned for a second meeting lasting 30 minutes, to monitor her progress. Anna had lost 800g, which everyone was pleased about. The dietician explained Anna’s weight loss in terms of her Body Mass Index (BMI), and plotted it on a graph. The dietician asked how Anna managed to cope with smaller amounts of food, to which Anna answered: “I’m trying to forget about food – I watch TV”, to which her mother then added: “In the start it was difficult because she gets so hungry and she complains all the time – but I tell her to take it slowly.” The dietician explained that unlike adults, children were not expected to reduce their calories to lose weight, but to eat what was recommended for their height and age. She went on to discuss portion control on the ‘Y’ plate, and how Anna should fill up on vegetables. As a health professional, the dietician is implied in the generational order surrounding Anna, and in an adult-child constellation, Anna is located within a system of authoritative generational ordering (Alanen, 2009: 160). At this point I would like to briefly mention an observation from a meeting with an Iraqi immigrant family with an obese daughter named Yasmin. Both parents attended, but unlike Anna’s mother, who controlled Anna’s meals, they seemed resigned to the fact that Yasmin ate noodles and sweets in her free time at school and they found it difficult to stop her. In fact, Yasmin was very different to Anna in her mannerisms and speech; she did not retain much eye contact with the dietician and looked down at the floor a lot while her parents spoke, and she had gained weight in between sessions, unlike Anna. Yasmin distanced herself from the dietician with her body language, but Anna did not do this.

20The dietician constructs Anna’s obesity within a discourse of ‘being and becoming’ by considering Anna’s present eating habits and how they can be ‘improved’. Her approach nonetheless placed less emphasis on aspects of Anna’s present life which influence her eating, such as her food world with peers. Hepworth argues that biomedical science tends to neglect the link between socio-cultural contexts of experience and behaviour, which appears to be the case in Anna’s meeting (Hepworth, 2007: 374). Studies show that children often copy what peers eat to define group membership, stressing the symbolic significance of food (Wills et al., 2009: 52), and Ørntoft reveals accounts of obese youngsters’ junk food consumption with peers (Ørntoft et al., 2005). This suggests that children’s food world outside of the home is an important area to explore. When I asked the dietician why she did not enquire about Anna’s social life, she explained that although it was important, she isn’t trained to explore this component of diet. However, Anna’s own account of her social world with food would give the dietician a clearer picture of her ‘being and becoming’, because a deeper knowledge of Anna’s present life might indicate her future (Uprichard, 2008: 304). Whilst this single study is not representative, it reveals how a child with an immigrant background like Anna, who is expected to succeed at many things, is under constant pressure from the need to fit in with peers and the need to acquiesce to parental demands.

Four is a crowd

  • 10 Anna’s brother did not participate and appeared somewhat bored. I cannot offer an explanation for w (...)

21In Anna’s third meeting, both Anna’s father and older teenage brother joined Anna and her mother, and the room was crowded10. The dietician told Anna that the focus was now on physical activity. Anna was asked about her eating, such as what snacks she ate during the day, and she answered these questions, explaining that her mother helped her with her meals and portion sizes. The issue of how much water Anna should be drinking came up, where the dietician recommended one litre per day. The following dialogue ensued:

Father: “She drinks too little”

Mother: “She doesn’t drink enough – we’ve told her she needs to drink to fill up. She comes home with her water bottle half full”

Dietician (to Anna): “Is it because it’s warm?”

Anna: “I just don’t think about it – I’m busy working in class”

22What then occurred was a disagreement between Anna and her mother about Anna’s water intake, which ended when Anna said angrily: “Yes I do!” before turning to the dietician. The dietician quickly steered the meeting back on course by drawing a diagram showing how the brain tricks the body into thinking it is hungry, when the body actually needs water. Anna was the minor in the generational order, flanked by both parents who spoke of her in the third person (‘she’), as if Anna wasn’t in the room. The dietician ‘rescued’ Anna by using her clinical expertise to regain control of the meeting, yet the question remained whether the dietician could have retained tighter control of the meeting if only one parent had been allowed in. The conversation then turned to Anna’s physical activity levels, and Anna explained that she attended dance and gymnastics a couple of times a week. The dietician explained that to prevent weight gain, Anna needed to be active 60 minutes daily, including weekends. Anna made it clear that she did not like outdoor activities. Anna’s mother presented a list of activities she encouraged Anna to do, from dancing to fitness and tai chi, explaining the days of the week and time-slots Anna could do them. The time slots were numerous and confusing: I wondered if this was an example of parental pressure on Anna. The following dialogue ensued:

Anna: “I don’t like walking”

Dietician: “If you could choose, what would you do?”

Anna: “Don’t know”

Father: “She gets up late at weekends, eat breakfast at midday – the day’s gone. But I do ask her to go for a walk with me”

Dietician (to Anna): “Yes, but you shouldn’t do what you don’t enjoy. You need to do something where you use your body – swimming?”

Anna: “I did go to swimming once”

Mother: “We used to go to the weekend swimming club. She just has to say it – she’s good at swimming”.

Dietician: “Why not Anna, when you like it?”

Anna: “I just don’t like being pressured all the time.”

Dietician: “You mean by the instructor? You could go when there’s no instructor there... what about winter skating?”

23Anna’s parents spoke of Anna’s ‘being and becoming’ from their perspective, where their aspirations for Anna were somewhat transparent. What really surprised me was what the dietician appeared to overlook: what did Anna mean by “pressure”? Could she have meant pressure from her parents, and not the instructor? Or was she self-conscious of her body? There had been little mention of Anna’s body-size in the meetings, as the focus was on her diet or activity levels. Indeed, Anna’s only reference to her body had been that as she wore trousers out so quickly, she was looking forward to being smaller and not having to keep buying new ones. This is an example of her discourse of ‘being and becoming’: she is looking ahead to what she wants to be in the future. Nonetheless, she may not have wanted to reveal more personal thoughts about her body with her family present. Childhood body perceptions affect identity in adulthood, because children do not just ‘become’ adults: they still carry memories of experiences with them into adulthood which shape the person they become, emphasising their ‘being and becoming’ (Uprichard, 2008: 310). This is confirmed by obese youngsters’ accounts which show how being bullied and called ugly names in childhood damages body-perceptions in later life (Ørntoft, 2005). In light of this, I asked the dietician later if she thought Anna didn’t like swimming because of her body-size. She replied that the topic was humiliating enough for Anna to have to discuss in front of her family, and she didn’t want to embarrass her further.

24In this section, it has been suggested that the dietician constructs Anna’s obesity mainly from a biomedical angle, using a discourse of ‘being and becoming’, yet very selectively, focusing on a future perspective. Moreover, in spite of Anna’s minor position in the generational order, the dietician tried to elevate her to the level of active agent in her life, advising her to choose activities she enjoyed, not what her parents suggested. The impression of Anna hitherto was one of a child whose eating was partly parentally-controlled, and who was under certain pressure to partake in different activities. As parental discourses were so prevalent in the meeting, the next section considers what these are, and how they shape meanings about obesity.

Parental discourses

25Anna’s mother reveals different parental discourses, such as being a good provider: “We change our food every day”, and exasperation: “I have tried everything”. In this section, the way in which parental discourses shape meanings about childhood obesity in the dietetic meeting will be considered. Food is important in Anna’s family life, and Jackson sees food as a powerful lens through which family life can be observed (Jackson, 2009). James et al., (2009) suggest that food offers a pretext for ‘doing family’, whilst Ikeda points out that parental discourses about food are often framed in nutritional discourses (Ikeda, 2007: 297). Anna’s mother demonstrated her knowledge of ‘healthy eating’ during the meetings several times. On one occasion, the dietician asked Anna about what vegetables she liked, and before Anna had a chance to answer, her mother said: “I don’t make aubergine or squash so much because the family’s not so keen. I use leeks and celery in soup, and carrots cut into cubes – she’ll eat it like that.” The dietician then asked Anna’s mother how often they ate vegetables, at which she replied: “Everyday, but the kids don’t eat it every day, only me and my husband.” Anna’s mother told the dietician that her husband did the shopping, but she decided what the family ate and cooked the meals.

26In this dialogue, we learn not only what Anna’s mother provides, but what she eats with her husband, what the family don’t like and how she serves Anna’s carrots. This was an impressively detailed account of food provision to give in just a few lines of dialogue, and Anna still remained quiet. It seemed to be important for her mother to impart that she not only provided the ‘right’ food, but she complied with the family’s tastes. Indeed, Coveney reminds us that mothers want to provide the ‘right’ food, with the ‘right’ nutrients, whereby biomedical discourses about nutrition organise family food habits, providing a standard by which ‘good parenting’ can be judged (Coveney, 2007: 220). This sets the general tone for parental discourses about food: parents have a role to fulfil, which amounts to ‘proper’ food provision. The generational order as a familial order within which children also participate is implied in Anna’s mother’s dialogue, because whilst she is ‘provider’, her children influence what they get to eat, through their own likes and dislikes. Anna’s mother explained how she warms Anna’s vegetables and serves them on the side, she gives Anna a smaller plate to eat on and she cuts Anna’s carrots into cubes. This shows that Anna’s obesity contributes to the structure of family relations and food systems in the home, and in this way, her ‘being’ is constructing her ‘becoming’, shaping generational relations simultaneously (Uprichard, 2008).

Food and family

27Various studies reveal that the concept of an ‘ideal’ family life exists amongst some parents, not least of all with regard to the ‘healthy family’ (Green et al. in Jackson, 2009: 205). James et al. (2009: 37) assert that the family is constantly being socially constructed through actions and relations between family members, especially children’s agency. This agency might include children’s demands for certain foods, which some parents are happy to acquiesce to, to keep family harmony (Brembeck, 2009: 130). In this way, children’s ‘being’ makes them co-constructors of family food systems as a consequence of their position in the generational order. As Anna herself demonstrated, once children get older, they spend more time socialising with peers (Frønes, 1995). Shohet & Ochs (2006) describe the family meal as an important ‘cultural site’ for socialising children in values, and for reinforcing the social order of family relations. This is echoed by Green et al, who describe the family meal as being steeped in nostalgia and as: “the means through which future identities as adults are formulated” (Green et al., 2009: 217). These concepts reinforce the idea that the parent-child generational order regulates children’s ‘being and ‘becoming’.

28In spite of idealised images of the harmonious family dinner (Murcott, 1997), family meals can also be battlegrounds, where children are reprimanded for not eating up, or having poor table manners (Lupton, 1996: 55). Anna’s mother’s stories also reveal tension around food, such as in the first meeting, where she complained that Anna ate too much toast, always took two portions and didn’t eat salad. Her mother’s dialogues reveal discourses of ‘parental responsibility’, ‘healthy eating’, and also a form of parental frustration, as the following shows:

Dietician (to Anna): “You’ve already made a positive change to your diet, Anna”

Mother: “I just hope she continues to eat more vegetables – before she didn’t eat enough.”

Dietician (to Anna): “What you’re doing works, and it would be great if you could continue. [...] It’s important that you’re happy – it’s hard if you have food on your mind all the time”

Anna: “Yes, before –“

Mother: “Yes, all the time. All she thought of was food – she used to go in the kitchen and nibble all the time”

29What the dietician gained from this was not Anna’s own outlook of ‘becoming’, where she could see herself continuing. Instead, she heard about Anna’s ‘being and becoming’ from her mother’s parental perspective. Anna’s mother appeared to use her position in the generational order to assert her ‘authority’ in the dietetic meeting. The dietician attempted to appeal to Anna’s sensibility: she wants her to continue to lose weight, and encourages her, but is overshadowed by Anna’s mother’s discourse, and her apparent aspirations for Anna. Anna seemed reduced to an almost invisible entity as this conversation took place.

Food as a pretext for maternal relations

30Women’s maternal position has been well studied: for example, Charles and Kerr (1988) portray how women feel obliged to nurture their families, whilst Douglas describes food provision as a transactional exchange, where mothers’ cooking efforts are rewarded with consumption (Douglas, 1982: 100). A newer perspective on women’s roles sees commensality as secondary to the cooking and serving of family meals, where the effort involved in creating family meals strengthens women’s relations to their family (Haukanes, 2007). These perspectives share a focus on the generational order, and a ‘need’ to nurture, and all efforts point to a future trajectory of children’s ‘becoming’. Using an economic analogy, children are worth ‘investing in’ for parents, in order to give them ‘good’ futures (Alanen, 2009: 167), and Anna’s mother demonstrates this not only with wanting to provide her with the ‘right’ food, but also offering Anna different paid activities. It is for this reason that the emphasis Anna’s mother places on food provision is so integral to understanding Anna’s perceptions of food, and how she has been socialised in eating, via habitus (Bourdieu, 1997). Anna’s mother constructs Anna’s obesity in her own meanings about Anna’s ‘being’, pointing to Anna’s diet and (lack of) physical activity. In this way, she considers Anna’s ‘being’ in a framework of what she isn’t ‘doing right’, while all the time looking ahead at what Anna ‘should’ be doing, for her future ‘becoming’.

31It has been suggested that meanings about childhood obesity are constructed through biomedical discourses which focus on food as nutrition, and that parental discourses are not only inspired by a nutritional discourse, but also one of parental responsibility, all of which are framed within a familial generational order. We will now turn to Anna’s discourse, and the fact that she seemed to be remarkably absent in the dietetic meeting.

A child’s discourse

32The title of this paper “But I’ve also tried” reveals a child’s frustration which was not explored in the meetings. Whilst Anna answered the dietician’s questions dutifully, there remained aspects of her private world which were never unveiled. Anna’s position in the meeting seemed minor because of her lack of dialogue, and she rarely had the chance to unfold her present world fully in discourses of ‘being and becoming’, which could point to her future aspirations (Uprichard, 2008: 304).

33As Anna’s dialogue was the least prolific in the meetings, I have chosen to focus on the significant things she did say, such as when the dietician discussed using the ‘Y’ plate for dinner in their first meeting:

Anna: “I prefer two portions”

Dietician: “So two portions mean something?”

Anna: “Yes”

Dietician: “So for dinner, you could divide two small portions on the ‘Y’ plate”

Mother: “She loves meat – eats too much”

Dietician: “This is Anna’s big challenge, controlling her pasta, rice and potatoes.”

Anna: “I think it’s dinner that’s the problem”

Dietician: “Shall we start looking at what you eat for dinner, then?”

34I wondered why the dietician didn’t ask Anna what taking two portions meant to her. Anna used a discourse of ‘being’ here by explaining her custom of taking food twice. Her mother interrupted, criticising the amount of meat Anna ate, and Anna pointedly told the dietician that dinner seemed to be the ‘problem’. Again, the dietician neglected to ask Anna what she meant by this, so Anna’s comment was left suspended and undisclosed. Instead, the dietician went on to discuss how Anna could reduce her dinner portions, returning to a biomedical focus. Some of Anna’s short responses appear saturated with revelations about her present life, without being unfolded. For example, her statement: “I just don’t like being pressured all the time” seems to encapsulate her ‘being and becoming’: she is feeling pressured and she doesn’t want to be. As an intelligent child, I imagined Anna would have perhaps explained what she meant by ‘pressure’ if given the chance, yet the dietician seemed to miss the opportunity to explore this. Anna’s response in the earliest piece of dialogue: “But I’ve also tried” might be interpreted as a call for help. These possible ‘openings’ for Anna to explain herself passed by unnoticed in the dietetic meeting, possibly because of parental interruptions, but also because the dietician’s discourse could not accommodate this exploration. In the generational order, the minor social position Anna seems to have in the meeting suggests passivity on her part. This is not to suggest that Anna’s child’s status is the only reason for her apparent submissiveness: accounts in Ørntoft’s book ‘Overweight’ reveal that obesity itself is a reason for shyness and lack of confidence. For example, obese youngsters often try to ‘hide’ themselves away not only because of their appearance, but also to avoid being a target for bullies (Ørntoft, 2005).

35I asked the dietician if it was typical for parents to take so much ‘space’ in dietetic meetings, and she explained that it was normal for parents to either ‘take over’, or simply let the dietician do the talking. The dietician also explained to me that immigrant families took the dietetic meetings very seriously and listened intently to advice. In my other observations of the Iraqi family, both parents attended on each occasion with Yasmin, whilst the “native” Danish families usually only had the mother present. Anna’s family demonstrated an attempt to control and monitor her eating and her exercise levels. In Anna’s meetings, a mainly biomedical and parental discourse appeared to regulate the extent of her agency, yet Anna seemed too quiet in these meetings. Her silence might be interpreted as a construction, being a response to her position in the generational order. Through parental discourses, a picture emerged of a family who strives to provide their child with the ‘best’ education and life opportunities, and the ‘best’ diet. It was transparent to me that Anna’s parents are in control: they paid for her education, were willing to pay for whatever activities she wanted, and provided ‘good’ food. In this social order, the ‘power relations’ Alanen suggests are prominent: Anna appears to have less ‘power’ in relation to her parents (Alanen, 2009: 161). At the same time, the data reveals that Anna’s obesity also impacts both on her family relations and the structure of food provision at home. Anna told the dietician that she is allowed to eat sweets and cake at the weekend, and soft drinks are allowed for birthdays and special occasions, which reinforces the idea that Anna’s position in the generational order as a child affords her some powers to structure the family food system. Some of the data obtained from the parental discourses about Anna seemed inconsistent, however. For example, on one hand, Anna’s mother monitored her lunchbox when she came home from school to see what Anna hadn’t eaten, whilst on the other, Anna was given pocket money which she told the dietician she used to buy noodles at the Junior Club. This was interesting, because Anna’s mother regulates her meals at home and at the same time allows Anna autonomy to buy ‘junk food’ at school. On this note, knowledge of Anna’s social life with peers may have been revealing for the dietician, because children tend to eat differently away from home. Indeed, peers represent more equal social relations, within a more level social order (Frønes, 1995). In the three meetings observed, knowledge was acquired about Anna’s food habits at home, and in some of her recreational activities, whereas there was little knowledge of her private food world. Quite apparent was a missing discourse of Anna’s ‘being and becoming’, because she never spoke fully and uninterrupted about her life. Alanen argues that in order to understand children’s lives, the generational structures behind children’s agency - or lack of agency – needs to be explored (Alanen, 2009: 170). The source of children’s agency is embedded in the social organisation of generational relations, and Anna’s powers of agency may have been constrained by a parental presence.

Conclusion

36This paper has endeavoured to show how meanings about childhood obesity are constructed in the meeting between the dietician, the overweight youngster and parents. I have argued for the validity of a single-case study, which is rather unique as it introduces a youngster from an immigrant family who attends a private school for scholastic achievers. Two key theoretical concepts have been used as analytical tools throughout the paper: Uprichard’s claim for more frequent and explicit references to ‘being and becoming’ in childhood constructions (Uprichard, 2008), and Alanen’s concept of the ‘generational order’ (Alanen, 2009). The findings reveal that whilst different meanings about childhood obesity are constructed in the dietetic meeting, these meanings emerge from mainly a biomedical or a parental discourse of ‘being and becoming’. The child’s meanings were conspicuously absent. The analysis has been framed in the idea that children are important social actors whose agency allows them to co-construct their social worlds (Qvortrup, 2009). The concept of children’s ‘being and becoming’ follows a future trajectory of children’s lives by appreciating that what children have to say about their present lives is important in conceptualising their futures. Uprichard maintains that without knowledge of children’s present ‘being’, we cannot appreciate how they envisage their futures (Uprichard, 2008). This concept has made it possible to isolate what is missing from the dietetic meetings observed: Anna had limited opportunity to unfold her private world with food, so a child’s discourse of ‘being and becoming’ was not developed.

37The concept of the generational order emphasises the social ordering taking place in Anna’s life both at home, and with health professionals. The dietetic meeting illustrates how this order of ‘power relations’ regulates children’s agency; the adults in the dietetic meeting have a ‘role’ to perform: the dietician advises Anna, whilst her mother controls her diet at home. The dietician’s mainly biomedical approach to Anna’s obesity included a discourse of ‘being and becoming’, and she also attempted to ‘bond’ with Anna. There were comments from Anna which the dietician did not seize upon, and which may have opened up a fuller dialogue of ‘being and becoming’ from Anna, such as the protest: “But I’ve also tried”. The dietician explained that her dietetic training does not cover sociological aspects of diet, therefore she did not enter into Anna’s private food world. It has been argued, however, that as food is a social concept (Caplan, 1997), it might be beneficial for the dietician to unfold Anna’s perspectives in order to gain a fuller picture of her life with food. The parental dialogues were framed in discourses of ‘being and becoming’, and included aspects of a nutritional discourse, ‘parental responsibility’, and also parental frustration. There were moments of tension in the meetings, where Anna seemed to be overpowered by her parents’ dialogues, emphasising her minor position in the generational order. Anna’s lack of agency meant that she had only minimal discourse in the meeting, thus it was not possible to gain a more nuanced picture of her private food world. No questions had been asked about Anna’s school life, and whether this may affect her diet. The concepts of ‘being and becoming’ and the generational order have supported the argument that obese children need to be given greater opportunity to speak about their private food worlds. The generational order was apparent in the dietetic meeting, with adult dominance, yet obese children’s position and agency might be developed by giving them more openings in the dietetic meeting to speak about their lives in a joint discourse of ‘being and becoming’. Moreover, a development in dietetic training which would incorporate knowledge of food’s social and cultural significance may help to facilitate this.

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Notes

1 Danish Ministry of Health www.sst.dk consulted 1.10.2011

2 Region Midtjylland data 2008,2009,2010

3 Interviews with dieticians in 2010

4 http://www.regionh.dk/topmenu/Nyt_Presse/Nyheder/2008+arkiv/Arkiv/Etniske+minoriteter+har+massive+sundhedsproblemer.htm?wbc_purpose=http%253a%252f%252_blank

5 http://www.cfk.rm.dk/projekter/sundhedsfremme+og+forebyggelse/afsluttede+projekter/v%C3%A6gtstop+for+etniske+minoriteter

6 http://news.bbc.co.uk/2/hi/6904640.stm consulted 2/12/2012

7 Data from interviews with RM dieticians 2010

8 Anna is 156cm. high and weighs 70 kg., with a child’s Body Mass Index (BMI) of almost 29, which is ‘obese’. For Anna to be ‘normal’ weight, she needs to lose 18kg. If Anna was an adult, in corresponding terms, her BMI would be over 30.

9 Union of Danish Dieticians www.diaetist.dk consulted 1.10.2011

10 Anna’s brother did not participate and appeared somewhat bored. I cannot offer an explanation for why Anna’s father and brother wished to attend. The dietician did not ask, but simply told them they could all sit down in the office.

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References

Electronic reference

Lisa Koustrup, Inge Wittrup, Morten Deleuran Terkildsen and Claus Vinther Nielsen, « “But I’ve also tried” », Anthropology of food [Online], S7 | 2012, Online since 21 December 2012, connection on 30 May 2017. URL : http://aof.revues.org/7117

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About the authors

Lisa Koustrup

Center for Public Health and Quality Improvement,Region Midtjylland, Danemark, superboots@mail.dk

Inge Wittrup

Center for Public Health and Quality Improvement, Region Midtjylland, Danemark, inge.wittrup@stab.rm.dk

Morten Deleuran Terkildsen

Center for Public Health and Quality Improvement, Region Midtjylland, Danemark, morten.terkildsen@stab.rm.dk

Claus Vinther Nielsen

Center for Public Health and Quality Improvement, Region Midtjylland, Danemark, claus.vinther@stab.rm.dk

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Copyright

Licence Creative Commons
Anthropologie of food est mis à disposition selon les termes de la licence Creative Commons Attribution - Pas d'Utilisation Commerciale - Pas de Modification 4.0 International.

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